1. Promoting Rational Use of Injections within National Medicine Policies World Health Organisation Dept. Essential Drugs and Medicines Policy Safe Injection Global Network Phnom Penn October 2002

2. A National Medicines Policy often not implemented due to lack of political will and corruption Expresses the goals and objectives set by a government for the pharmaceutical sector and identifies the main strategies for achieving them –specifies the roles of all stakeholders (public and private) –specifies government aims, decisions & commitments –should be concerned with: equitable access, ensuring drugs are of good quality, safety and efficacy, promoting correct use of drugs

3. Every country needs a national drug policy because of: medical reasons –25-40% of the world population has no access to drugs –up to 50% of the worlds drugs may be used inappropriately –substandard and counterfeit drugs are not infrequent cost reasons –drugs are 20-40% of health budgets - antibiotics & injections are most expensive the need for coordinated multiple interventions –single interventions do not change behaviour long-term

4. Up to 56 % of primary care patients receive injections - > 90% may be medically unnecessary % of primary care patients receiving injections Chart date from: Quick et al, 1997, Managing Drug Supply ä 15 billion injections per year globally ä half are with unsterilized needle/syringe ä 2.3-4.7 million infections of hepatitis B/C and up to 160,000 infections of HIV per year associated with injections

5. % drugs that are prescribed unnecessarily estimated by a comparison of expected versus actual prescription Chalker HPP 1996, Hogerzeil et al Lancet 1989, Isah et al 2000

6. CLINICAL PRACTICE Prior Knowledge Habits Scientific Information Relationships With Peers Influence of Drug Industry Workload & Staffing Infrastructure & Availability Authority & Supervision Societal Information Personal Workplace Workgroup Social & Cultural Factors Economic & Legal Factors Many Factors Influence Drug Use

7. Changing a Drug Use Problem: An Overview of the Process 1. EXAMINE Measure Existing Practices (Descriptive Quantitative Studies) 2. DIAGNOSE Identify Specific Problems and Causes (In-depth Quantitative and Qualitative Studies) 3. TREAT Design and Implement Interventions (Collect Data to Measure Outcomes) 4. FOLLOW UP Measure Changes in Outcomes (Quantitative and Qualitative Evaluation) improve intervention improve diagnosis

8. Impact of multiple interventions on injection use in Indonesia Source: Long-term impact of small group interventions, Santoso et al., 1996 Interactive group discussion (IGC group only) Seminar (both groups) District-wide monitor- ing (both groups)

9. Injections Antibiotics No.drugs Source: Sisounthone B, WPRO-EDM Newsletter, March 2002; 1(1):4

10. Reducing injectables in WHO’s model EDL SIGN recognised frequency of injectables in 11th EDL nature of problem (plus consequences) is identified and presented to secretariat of model EDL (EDM) –136 out of 306 active ingredients are injectables –173 injectable formulations –<50% injectables had enough information to decide syringe size –injectable ingredients listed problem presented to expert committee of model EDL expert committee agreed to: –review all injectables by the Cochrane Collaboration –insert a statement in the 12th model EDL : “ those who supply injectables should supply the necessary equipment to give them in a sterile way ”

11. Review of 30 studies in developing countries size of drug use improvements with different interventions Improvement in outcome measure (%) 0102030405060 Large group training Small group training Diarrhoea community case mgt ARI community case mgt Info/guidelines Group process Supervision/audit EDP/Drug supply Economic strategies None/minorModerate Large Adapted from: Ross-Degnan et al, Plenary presentation, Conference on Improving the Use of Medicines, 1997, Chiang Mai, Thailand.

12. 12 national strategies to promote RUD 1. Mandated multi-disciplinary body to coordinate medicine use policies 2. Evidence-based standard treatment guidelines 3. Essential Drug Lists based on treatments of choice 4. Drug & Therapeutic Committees in hospitals 5. Problem-based training in pharmacotherapy in under-grad. training 6. Continuing medical education as a licensure requirement 7. Supervision, audit and feedback 8. Independent drug information e.g bulletins, formularies 9. Public education about drugs 10. Avoidance of perverse financial incentives 11. Appropriate and enforced drug regulation 12. Sufficient govt. expenditure to ensure availability of drugs, equip, staff

13. National policies to reduce unsafe inapprop. injections A national task force – a subcommittee of the NDP body - to assess unsafe inapprop. injections and plan action Select appropriate injectable drugs and equipment –public sector EDL, market withdrawal of inappropriate injections –increase availability of approp.injections (with enough equip) & alternatives –reduce availability of inappropriate injections through effective registration of drugs & dispensing outlets, enforcing Px-only regulation Train healthcare workers and the public on approp. safe use Regulate and monitor promotional activities and material Establish functional drug and therapeutic committees Eliminate economic incentives encouraging injection over-use –prescriber salaries from drug sales, especially expensive injections –dispensing fees that are a % of drug costs –flat prescription fees